Updated: May 2
Why You and Your Clients Should Expect to Have A Different Experience at the Hospital vs. a Home Birth or at a Birthing Center
EDC has been on a mission training the next generations of doulas to do things different and better. We pride ourselves on going against the grain. EDC has always believed in and respected a blended space where life-saving modern medicine meets ancestral women’s wisdom regarding pregnancy and childbirth. We’ve always taught our doulas to advocate for their clients – to speak up and stand up. And we’ve always allowed our doulas to run their business they way they see fit without restrictive scope of practice rules and policies that conflict with their own personal and religious morals and values. They have complete autonomy to run their business how they see fit.
We’ve also been open and transparent – shooting straight from the hip. So, without wanting to sound mean or rude – I’ll jump right on it.
You cannot walk into a hospital and expect or demand to have the exact same birthing experience as you would in an out-of-home birth. You just can’t! If you do, you are potentially setting yourself up for a whole lotta disappointment and frustration – and a whole lot of misplaced anger.
Why Women Choose Hospital Births
Women want options and a sense of safety (perceived or otherwise).
Women want healthy mom healthy baby.
They expect potential medical complications to be foreseen and taken care of before there is an emergency – they are okay with medical interventions and all the hospital rules and policies doctors follow. They make an informed choice to birth their baby there. They sign consent to treat forms upon admission and trust their birthing team.
They want pain medication – we don’t have our wisdom teeth extracted without pain medicine – some women are all about options!
A woman may not be medically eligible for a an out of hospital birth because of a medical condition that will exclude her. Midwives can only care for women with low-risk pregnancies.
Sadly, there may not be any other options available. They may not have a choice where they have their baby because their insurance providers does not cover midwifery care and/or out of hospital births. Or it could be simply because there are no practicing midwives in their area.
Why Women Choose a Home Birth or Birth Center
Women want a natural childbirth experience.
Women want options and a sense of safety (perceived or otherwise).
Women want healthy mom healthy baby. Women want a natural birthing experience with little to no disruptions to the natural process and little to no interventions.
Women want to fully experience childbirth without pain medication.
Midwives vs. OBs, doulas vs. labor and delivery nurses, midwifery model of care vs. medical models of care, hospital birth vs. home birth – it’s all so confusing for most families, and the toxicity of the “us against them” mentality going around all over social media from the natural birthing community with many so quick to judge, blame, and cast stones is not making it any better for anyone – not the families we serve, not the medical community, and most definitely not for the natural birthing community. Doula sister, I can guarantee you, your distain and negative energy is wasted, and it is most definitely causing more harm than good.
Covid-19 has been the perfect example of that. It was like hospitals were just waiting for an excuse to exclude doulas from the delivery room. NO, WE DO NOT WORK FOR THE HOSPITAL (not yelling at you but saying it louder for those in the back) and the patient/our client has every right to hire whoever she wants as her doula – despite what hospital administrative policies have been put into place – BUT remember they hold all the cards right now. They literally CAN keep doulas out. And they did!
Is it really any wonder though? There are too many doulas and natural birth “advocates” (I use that term so loosely) out there spreading false information, throwing fits, acting a fool, placing blame, and burning bridges instead of working as a team to create real change, advocating the right way, and making things better for mommas and babies – not worse.
So, what is a doula to do? More on that below, but first let us all remember that ultimately, all women want a positive childbirth experience, and women are free to choose which way and how to achieve that.
Women want a positive childbirth experience that fulfils or exceeds their prior personal and sociocultural beliefs and expectations. This includes giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from birth companion(s) and kind, technically competent clinical staff. Most women want a physiological labour and birth, and to have a sense of personal achievement and control through involvement in decisionmaking, even when medical interventions are needed or wanted. WHO Recommendations Intrapartum Care for a Positive Childbirth Experience
Pregnancy and birth should not be an “us against them” mentality with OBs against midwives and doulas against L&D nurses. At the end of the day, we are all on the same team. We all have the same goal - healthy mom and healthy baby. How we achieve that goal is just … different!
So, what is the difference between a hospital birth and a home birth? What is the difference in how OBs and midwives care for their patients? First, we need to look at the differences in the models of care.
Medically Led Models of Care
The medically led models, or what some are currently being referred to as the “collaborative” model of care in obstetrics and gynecology, is still heavily driven by medical malpractice insurance companies, it is fear-based and heavy on the expectant management for medical interventions (not fear of birth itself –fear as in head off any potential problems before it possibly becomes a problem for fear of being sued kinda fear), and best practices are decided on by The Man! No not men – The Man. More on that in a minute too.
The practice of obstetrics and gynecology continues to evolve. Changes in the obstetrician-gynecologists workforce, reimbursement, governmental regulations, and technology all drive new models of care. The advent of the obstetric hospitalist is one new model, and the development of team-based care is another. Increasingly, obstetrician-gynecologists are becoming employees of health care delivery systems, and others are focusing the scope of their practices to subspecialites. As new practice models emerge, the specialty of obstetrics and gynecology will continue to change to meet the health care needs of women. Clinical Obstetrics and Gynecology
Midwifery Model of Care
The midwifery model of care is client-focused, approaching childbirth with more of an expectant approach to childbirth, meaning that they wait to see then act accordingly instead of reacting just in case, it’s about minimizing interventions and interruptions to the birthing process, it’s about allowing birth to be a normal life event, not one that needs to be treated or controlled, and it’s about hands-on guided and continuous support. You can read more here.
So Why All the Toxic Hostility? The Us Against Them Mentality? Where Did It Come From? How Did We Get Here?
Well for starters, birth in America has changed over the past almost 300 years. Pregnancy used to be a beautiful, normal and routine experience. It was a celebrated rite of passage. Women served and supported women in birth and it wasn’t treated like an illness. Birth was seen as a natural experience and not as a medical emergency. Were there obstetrical emergencies 100, 200, 300 or more years ago? Sure. There still are today, even with all the medical advancements. However, women have been birthing babies since the beginning of time, without heavy medical interventions. So, what changed? How did we get to this place where women now routinely birth in hospital – where the sick and injured go?
To understand how we got here, we need to look at the past. Yes, despite what society is telling us today, we need to understand the lessons of our past, so we can learn from it and do better for future generations. You can read The History of Midwifery and Childbirth in America: A Timeline for a complete history.
I’ll break down the major highlights here, but you’ve heard the phrase, “If ain’t broke don’t fix it” right?
Well, they broke it! Childbirth was taken out of the hands of women and given to the governmentally regulated medical world. Here’s how:
Starting in Colonial America in around the 1600s, only women attended women in birth, and it was considered indecent for men to attend births. Starting in 1716, New York City (of course), required midwives to be licensed. (Some falsely believe midwives were first required to be licensed in the 1900s solely to take midwifery out of the hands of Black women. But that simply is not true. Licensing started well before that – and in the North.) Witchcraft was on the decline, the Salem Witch Trials happened in 1692, so that makes sense, and doctors slowly started taking the place of healers/midwives in urban areas. These untrained and uneducated “doctors” were men. The hundred years from 1751 to 1850 gave way to the first state and federally run hospitals, the first formal medical school was chartered in Philadelphia, doctors had to be licensed in New York (of course), the first formal midwifery school was opened, The American Medical Association was founded, and the first medical society was organized. The best part - we won our independence from Brittan and the Declaration of Independence was signed in 1776. With the advancements in education and regulation of medicine, by the end of the 18th century, most people assumed that midwives were uneducated and/or did not have the necessary experience to safely care for women in childbirth. Somehow, they came to believe that women suddenly were emotionally and intellectually incapable – after thousands of years – childbirth was being taken out of women’s hands and given to the governmentally regulated medical world, which resulted in a huge shift in urban middle-class families, and midwives were replaced by doctors. In the 1800s we fought another war – the Civil War – and President Lincoln issued the Emancipation Proclamation, freeing slaves. Formal nursing schools were established in New York.
By 1900, about half of our nation’s birth were attended by a physician but less than 5% of births happened in hospital. Twilight sleep (early anesthesia), only available in hospital, was introduced in the late 1800s, which was appealing to women. But one of the biggest impacts on birth in the 20th century happened by the 1920s, when hospitals became for profit organizations, and were no longer predominately run by nonprofit religious charities. Doctors were in contract with hospitals (early form of medical insurance) and a newfound money maker was discovered – surgery. Cha-Ching! Medical societies and malpractice insurance were formed to handle cases of medical malpractice. Doctors within the society formed alliances with one another and would testify in court for one another. Physicians moved from lower, to middle, then into upper-class society, while midwives on the other hand were not seen as professionals, they made little-to-nothing, and had no power in society. Midwives were generally caring for women who could not afford a doctor and/or lived in rural areas. Interestingly, by 1910, the Flexner Report revealed that 90 percent of practicing doctors were still without formal college education and most had attended substandard medical schools. The recommendation was for most medical schools to close, leaving only the best to remain in business, and to use the medical model by Johns Hopkins. In 1914, the first maternity hospital opened, and the New England Twilight Sleep Association was formed. In 1915, the Association for the Study and Prevention of Infant Mortality published a paper that described childbirth as being a pathological process, that it was not a normal function, and that midwives had no place in childbirth. And in 1915, the American Association of Labor Legislation drafted the first health insurance bill, that would cover medical costs, sick pay, maternity benefits, as well as death benefits. But health insurance disappeared during the Roaring 1920s. By this time, doctors believed that “normal” births were rare, and interventions were needed to prevent any trouble. It was believed that birth was damaging to women and they need to be saved. Natural labor and birth became controlled at the onset of labor. Women were systematically sedated during the first stages of labor, given ether during the second stage, given an episiotomy for easier delivery with forceps, the placenta was extracted, and then more medication for the uterus to contract and for episiotomy repair. Maternal mortality rates between 1900 to 1930 were around 600-to-700 deaths per 100,000 births. Today in the United States, the maternal mortality rates are around 660 per year, out of almost 4 million births, or about 17.4 per 100,000 pregnancies. We’ve come a long way in the last 90 years.
In 1925, 5 midwifery schools were created to meet the needs of populations of women who were lived in rural areas, who were poor and could not afford doctors, had language barriers, and for those who were discriminated against by race and/or culture. (Do we think midwives were not already serving this population of women? Or did the government/licensing want control?) The Stock Market crashed in 1929. In 1930, the American Board of Obstetricians and Gynecology was established separating general practitioners from specialists. Blue Cross health insurance, a hospital-based program was created. In 1932 began the Dust Bowl. Infant death rates rose from 40 to 50 percent from 1915 to 1929. It was thought due to either inadequate prenatal care or excessive/improper use of interventions during birth. By 1935, 37 percent of births were in hospital. Twilight sleep was now used in all hospital births. By 1939, 75 percent of all urban women gave birth in hospitals. And by 1940, private insurance had 3.7 million insured, and Blue Cross had more than 6 million insured.
Japan attacked Pearl Harbor on December 7, 1941, and the United States entered WWII. More than 3 million women worked war-related jobs during the war. My own grandmother worked on the shipyards. The Baby Boom reached its peak in 1947. American’s opposition to national health insurance grew while other countries expanded health insurance.
The family-centered maternity model of care was introduced in the 1950s and 88 percent of births were in hospital. Midwifery organizations introduced the philosophy that pregnancy and childbirth were a normal process. Lamaze was introduced by Dr. Robert Bradley and Dr. Ferdinand. Columbia-Presbyterian-Sloan hospital in New York City was the first mainstream hospital to allow nurse-midwives to practice midwifery in 1955. La Leche League was founded in 1956. By the 1960s, 97 percent of childbirth took place in hospital. Birth control became available. In 1963, came The Feminine Mystique and along with it, feminism. The Civil Rights movement ensured racial and social justice for Black Americans when the Civil Rights Act was signed into law in 1964. Medicaid and Medicare were signed into law in 1965. The Vietnam war was escalating.
In 1970, national certification in nurse-midwifery programs were in place and all 3 branches of our U.S. military began training and using nurse-midwives. HMOs were created. The Farm was started in 1971 and Ina May Gaskin published Spiritual Midwifery. 1973 – Roe vs. Wade legalized abortion. The concept that health care was a right and not a privilege caught on and there was a health rights movement that included patient rights, informed consent, access to medical records, rights to participate in medical decision-making, and a right to due process for involuntary mental institution admissions. The movement in the 70s also focused on de-medicalizing normal life events like birth and dying. Hospice care was created, and homebirth was being normalized again. Teen pregnancy was an “epidemic” into the mid-1970s. Women medical students rose to 25 percent by the end of the 70s. The conflict between midwifery and homebirth vs. physicians and hospitals was the most bitter and hard fought between the medical profession and the women’s movement. A conflict that obviously still exists. During the 70s, doctors who offered services in emergency situations at homebirths were threatened with loss of their hospital privileges, as well as their medical licenses.
AIDS had the world’s attention in the 1980s. The Midwives Alliance of North America (MANA) began in 1982, and medical malpractice/liability insurance companies almost immediately began to completely stop covering nurse-midwives altogether, or they made the premiums too expensive. In 1983, The Federal Trade Commission prohibited insurance companies from discriminating against doctors who worked with nurse-midwives. In 1985, the American Medical Association began legislation to regulate all non-physician healthcare workers, so they could not practice independently from a physician. The American Academy of Family Physicians were adamantly opposed to nurse-midwives, issuing formal statements of their beliefs in in 1980, 1990, and in 1993, which stated nurse-midwives should only be allowed to work non-independently from physicians, and that all payments should have to go through a physician. The greatest challenge for nurse-midwives to practice midwifery in the 1980s was finding and affording adequate malpractice liability insurance.
By the 1990s, HMOs and PPOs (Managed Care Organizations) dominated medical insurance coverages, that most often did not allowed for midwives to be in-network providers, further driving a wedge between women and their access to midwifery care. It all came down to cutting costs. Midwives attract more women in their childbearing years – and families in their childbearing years use more healthcare. Managed care organizations began buying out birthing centers. In 1992, New York state signed into law the Professional Midwifery Practice Act, which defined midwifery with a specific scope of practice, and mandated a board to regulate midwifery. In 1993, the World Wide Web software was released to the public. In 1994, Clinton’s plans for universal health care collapsed, resulting in approximately 1 million people losing their healthcare coverage. NARM offered its first written examination for direct-entry midwives and expanded to entry-level midwives in 1996, Federal laws passed requiring state Medicaid programs to cover prenatal and childbirth medical care provided by nurse-midwives.
Thirty years later, licensing standards for midwives still vary state-to-state, and direct-entry midwifery is still illegal in many states. In addition, direct-entry midwives’ sharp criticism of and isolation from the medical profession makes it practically impossible for them to secure adequate medical backup.
Where Did This Leave Us?
It’s left midwives fighting to practice midwifery in a still oppressive system.
It’s left us all with a misplaced toxic “us against them” hatred and resentment.
It’s left some women having limited options for birth. With women having to have a birth experience less than desired simply because she has no other option – either financially or because there are no midwives practicing in her area.
And, it’s left doulas being lied to, not understanding their place, how to advocate for their clients, and not sure how to do their job!
Change Is Happening
This may come as a surprise to most, but the women who have fought before us and the women that continue to fight today ARE making change. The people – the birthing teams who serve women and children – are also working hard to make changes for the better.
Hospital births have greatly improved over the past 30 years. The pendulum is swinging back, slowly I’ll admit, to a time when birth was not treated like a medical event but a natural part of life that normally doesn’t need medical intervention. But it is happening.
Long gone are the days, that I can personally attest to from my own personal birthing experiences, of the 80s and 90s when we labored lined up behind curtains like in the ER, and then were wheeled into a labor that resembled an operating room, with legs spread wide in stirrups, and doctors numbed and cut without even saying a word. There really was no informed consent in the 80s from my own experiences. It started getting better in the 90s, it continues to get better, but there is still room for improvement for sure.
Hospitals have worked, and continue to work extremely hard to create a more natural, home-like environment. They have expert committee after committee studying and implementing evidence-based, best practices. Maternal and infant mortality rates are taken extremely seriously – despite what some may think. They literally have teams set up that’s sole purpose is improving outcomes for mom and baby. They drill informed consent into doctors and nurses – hard – even if a lot of you think they don’t.
But at the end of the day – they (doctors/nurses/hospital staff) have rules to follow, protocols to follow, hospital boards to answer to, attorneys to answer to, malpractice insurance to answer to. They must do what The Man says, or they lose their jobs, their livelihoods, and in worst case scenarios – their freedom if they are sued and found guilty of any criminal charges.
Sometimes they do witness the beautiful, natural birth experiences with no interventions when everything goes smoothly, and they also see real life emergencies day in and day out too. They know that second’s matter when saving a mom and baby. They know mom has signed all consent forms to treat when being admitted to the hospital, so no, she may not have time to stop and ask for permission every single time she has to touch mom. Believe me, they know what informed consent is and so do the doctors.
So, the next time your are ready to pounce because a women was informed on risks and benefits about what you deem as an unnecessary medical intervention for failure to progress (whatever pick something), and you want to scream that if they’d just leave mom alone and stop “bullying her” (informed consent is not bullying) she would be able to progress naturally – remember they have very strict rules and protocols to follow – literal algorithms/flow charts with timelines etc. that have to be followed. And remember, that nurse or doctor may very well agree with you – but their hands are completely tied!
Expectant moms and doulas you need to remember - birth wishes are fine. Doing things as close to how mom wants is fine IF/WHEN possible.
But NO! You and mom do not get to walk into a hospital and demand that they do it your way. They will do their best to ensure mom has a positive birthing experience – but bottom line – they have a job to do. If you want it your way – a more natural way without any medical interventions/timelines/interruptions – birth at home with a midwife. If that is not an option, you need to have realistic expectations, take the chip off your shoulder, and help mom have the very best birthing experience possible.
Also remember this, midwives have rules to follow too – not nearly as many, but all the same. They too have malpractice insurance and state boards that regulate how they practice. I've seen the doula and midwifery world tear apart another midwife on social media (Instagram) because the midwife DID inform her client of the risks and benefits - the real risks of failure to progress - and people lost their cotton-pickin' minds and called her a bully and every other name in the book.
Who Is Really to Blame for This Big Ole Mess?
It’s the entire oppressive system working against women and natural childbirth. It’s the elitists with all the power, the federal and state governments, politicians, the universities and institutions, the licensing boards, the hospital boards/corporations, the malpractice insurance companies, the attorneys, big pharma, the associations, … on and on all dictating how medicine is practiced in this country – how an OB can or cannot treat their patient – how a labor & delivery nurse has to care for her patient - how birth happens in this country.
AND, it’s the doula certifying agencies in bed with all the aforementioned, and their idea of scope of practice telling you what you can and can’t do, heavy on their policies and procedures, their rules!
So, if you’re pissed off at anyone and fightin’ mad - take it out on The Man (no not men) and not the OB or L&D nurse who gives their heart and soul every day for mommas and babies – just like we do!
So, What Is the Biggest Difference Between Doulaing at a Hospital Birth vs. Home Birth?
Although there are differing lenses and approaches to childbirth between obstetrical and midwifery training and the models of care, you as the doula, however, you will still advocate, support and care for your client the exact same way regardless of where she decides to have her baby.
But the biggest difference will the ru